Situation
You are a mental health nurse dealing with patients
currently EXPERIENCING A CRISIS. You use your
knowledge on crisis management to help these
patients. The following questions apply.
1. In the rape crisis center, a woman is being seen a few
days after she was raped. She reports that she has not had
any appetite, she is experiencing anxiety and
depression, and that she has been having nightmares.
You as the nurse make an assessment on the woman to
determine if it is appropriate for her to be admitted to the
hospital. Which of the following priority questions
should the nurse ask the woman?
A. The client’s reaction to the event, including any
suicidal thoughts. SAFETY AND SECURITY
B. The client’s perceptions of her current skills for
coping with the event.
C. The availability of the client’s personal support
systems.
D. The effect of the event on other aspects of the client’s
life.
2. An anxious, sobbing 19 year old is brought to the
crisis shelter for an interview. She says, “I think I am
pregnant but I don’t know what to do!” Which of the
following nursing interventions is most appropriate for
her situation at this time?
A. Ask the client about the type of things that she had
thought of doing.
B. Give the client some ideas about what to expect to
happen next.
C. Recommend a pregnancy test after acknowledging
the client’s distress.
D. Question the client about her feelings and possible
parental reactions.
3. You’re the nurse on duty when you saw an anxious
41-year-old client say that she would “rather die than be
pregnant.” Which of the following responses by the
nurse is most helpful?
A. “Try not to worry until after the pregnancy test.”
B. “You know, pregnancy is a normal event.”
C. “You’re only 40 years old and not too old to have a
baby.”
D. “I see you’re upset. Take some deep breaths to
relax a little.” ACKNOWLEDGE
4. You were doing some charts when a client comes to
the crisis center in a very distressed state. He tells you
that he just cannot get over being fired from his job last
week. He says that he already asked for help and talked
to friends. He says, “I’ve tried everything to get through
this, but nothing is working. Please, help me!” Which of
the following should you, as the nurse, use as the initial
crisis intervention strategy?
A. Referral for counseling.
B. Support system assessment.
C. Emotion management. Letting patient express his/her
feelings
D. Unemployment assistance.
5. Getting the client’s significant others involved in
helping with the immediate crisis as soon as possible is
one of the major roles in crisis intervention. You as the
nurse determine that the support persons are prepared
to help when they verbalize which of the following?
A. The name and phone number of the client’s physician.
B. Emergency resources and when to use them.
C. The coping strategies they are using.
D. Long-term solutions they plan to tell the client to use.
Situation
You are a nurse tasked to work with patients coping with
their illnesses.
6. A client was diagnosed with an acute cardiac illness.
The nurse should determine that the client lacks
understanding of her illness and her ability to make
changes in her lifestyle when they verbalize which of
the following statements?
A. “I already have my airline ticket, so I won’t miss
my meeting tomorrow.”
B. “These relaxation tapes sound okay; I’ll see if they
help me.”
C. “No more working 10 hours a day for me unless it’s
an emergency.”
D. “I talked with my husband yesterday about working
on a new budget together.”
7. You just admitted a 19-year-old client who was
recently diagnosed with leukemia. What is the most
appropriate short term goal for the nurse and the client
to establish?
A. Accepting his death as imminent.
B. Expressing his angry feelings to the nurse.
C. Decreasing interaction with peers to conserve energy.
D. Gaining an intellectual understanding of the illness.
1. let the patient verbalize feeling
2. acknowledge patient feeling
8. The client hospitalized for diagnosis and treatment of
atrial fibrillation states to the nurse, “Please hand me
the telephone. I need to check on my stocks and bonds.”
Which of the following responses by the nurse is most
therapeutic?
A. “You will get more upset if you make that call.”
B. “You have atrial fi brillations. Let’s talk about
what that means.”
C. “You really don’t care about the fact that you’re sick,
do you?”
D. “Do you realize you have a life-threatening
condition?”
9. The colostomy club made arrangements to meet with a
client who will undergo a bowel surgery. Which of the
following is accomplished when a representative of the
colostomy club visits the client preoperatively?
A. Letting the client know that he has resources in the
community to help him.
B. Providing support for the physician’s plan of therapy
for the client.
C. Providing the client with support and realistic
information on the colostomy.
D. Convincing the client that he will not be disfigured
and can lead a full life.
10. One of your patients in the ward directs profanities at
you, the nurse, then abruptly hangs his head and pleads
to you, “Please forgive me. Something came over me.
Ugh, why do I say those things?” As a knowledgeable
nurse, you interpret this as which of the following?
A. Neologism using a word when it can have 2 or more
meanings:play on word
B. Confabulation
C. Flight of ideas jumping from one topic toanother
D. Emotional lability readily changeable and unstable
Situation
You are a nurse tasked to care for patients experiencing
stress and anxiety. You are to apply the nursing concepts
you’ve learned about this topic to effectively care for
these patients.
11. You are a nurse tasked to care for patients
experiencing stress and anxiety. You are to apply the
nursing concepts you’ve learned about this topic to
effectively care for these patients.
Lack of information stress anxiety levels
A. Telling her to distract himself with games and
television
B. Reassure her that she will come through the surgery
without incident
C. Explaining to her what happens before and after
surgery
D. Asking the surgeon to refer her to a psychiatrist who
can work with her to diminish her anxiety
12. You are discussing the concept of anxiety to the
student nurses in your unit. You explain that anxiety
occurs in degrees, from a level that stimulates productive
problem solving to a level that is severely debilitating.
The students respond correctly when you ask that at a
mild, productive level of anxiety, one will expect to see
which of the following cognitive characteristics of mild
anxiety?
A. Slight muscle tension. motor
B. Occasional irritability. emotional
C. Accurate perceptions.
D. Loss of contact with reality
13. You followed up a question to the student nurses.
They answered you correctly when they stated that as a
client’s anxiety level increases to a debilitating degree,
they would expect which of the following psychomotor
behavior indicating the panic level of anxiety:
A. Suicide attempts or violence.
B. Desperation and rage. emotional
C. Disorganized reasoning.
D. Loss of contact with reality.
14. You admitted a patient dealing with personal issues
and painful feelings. Which of the following is a crucial
goal of therapeutic communication when helping this
client?
A. Communicating empathy through gentle touch
B. Conveying client respect and acceptance even if
not all of the client’s behaviors are tolerated
C. Mutual sharing of information, spontaneity,
emotions, and intimacy
D. Guaranteeing total confidentiality and anonymity for
the client
15. You are doing a follow up visit to the home of a
client diagnosed with Alzheimer’s disease. You are
assessing the stress level of the patient’s spouse, the
primary caregiver. Which of the following questions is
most appropriate for assessing the spouse’s level of
stress?
A. “So, what is a typical day like for you?” Open ended
questionexploration
B. “What do you do to relieve stress for yourself?”
C. “May I arrange for some part-time help for you?”
D. “Being a full-time caregiver must be very stressful,
isn’t it?”
Situation
You are a nurse tasked to care for patients with
SCHIZOPHRENIA. You use your knowledge on this
concept to effectively and safely care for your patients.
16. You are caring for a patient diagnosed with paranoid
schizophrenia. The patient reports hearing a voice
saying “Do not remove your cap or they will be able to
read your mind.” Which of the following responses is the
most therapeutic for this patient?
A. “Who are ‘they’?”
B. “Why would someone want to read your mind?”
C. “I do not believe that anyone can read another’s
mind.” Disagreeing
D. “It must be very frightening to believe that
someone can read your mind.” acknowledge
17. A patient diagnosed with a history of paranoid
schizophrenia and chronic alcohol abuse was admitted
to your unit. The patient has been taking Olanzapine for
14 days and has not consumed alcohol in the last 5 days.
They report shaky hands and trouble sleeping because of
frequent nightmares. The patient verbalized their concern
that olanzapine may be causing these problems. Which of
the following is your most therapeutic response to this
patient?
A. “These are not typical side effects for that drug.”
B. “Just ignore the symptoms. They will go away in just
a few days.”
C. “These symptoms are more likely a result of not
drinking alcohol for 5 days.”
D. “It is possible, since this medication is contraindicated
in those who abuse alcohol.”

18. A patient with a history of violent command
hallucinations was observed to be mumbling erratically
while making threatening gestures directed toward a
particular staff member. Which of the following
interventions is most appropriate when caring for
patients with violent command hallucinations?
A. Ask the client to explain the cause of anger.
VERBALIZATION
B. Place the client in seclusion to help de-escalate anger.
C. Inform the client of pending restraint if behavior does
not subside.
D. Observe the client for signs of escalating agitation.
19. A patient diagnosed with paranoid schizophrenia
was admitted to your unit. You include the nursing
diagnosis of Disturbed thought processes secondary to
paranoia in the patient’s care plan. Which of the
following approaches is most appropriate for this
patient?
A. Avoid laughing or whispering in front of the client.
B. Begin to identify social support in the community.
C. Encourage the client to interact with others on the
unit.
D. Have the client sign a written release of information
form.
20. The mother of a client diagnosed with paranoid
schizophrenia visiting her son 2 days after his admission
to the psychiatric unit approaches a nurse and states, “He
is still talking about how the government is controlling
his thoughts.” What is the most accurate nursing
appraisal of the mother’s statement? Antipsychotic 5-9 days
A. The mother’s expectations of her son are realistic.
B. The mother’s concern is reasonable.
C. The mother should request a medication adjustment.
D. The mother requires further education regarding
the client’s diagnosis.
Situation
You are tasked to care for Zoro, a patient newly
diagnosed with obsessive compulsive disorder.
You use your knowledge to effectively and safely
care for the patient.
21. Zoro is utilizing a defense mechanism commonly
used by patients with obsessive compulsive disorder.
Which of the following defense mechanisms is this?
A. Suppression. Sinadyang Kalimutan: voluntary blocking
B. Repression. Hindi sinadyang kalimutan: involuntary blocking
C. Undoing.
D. Denial.
22. You start your assessment on Zoro. Which behavioral
symptom would you expect to assess in this patient?
A. The client uses excessive hand washing to relieve
anxiety.
B. The client rates anxiety at 8/10.
C. The client uses breathing techniques to decrease
anxiety.
D. The client exhibits diaphoresis and tachycardia.
phsysiological
23. Which cognitive symptom would you expect to
assess in Zoro who has obsessive compulsive disorder?
A. Compulsive behaviors that occupy more than 4 hours
per day. Behavioral
B. Excessive worrying about germs and illness.
Thinking
C. Comorbid abuse of alcohol to decrease anxiety.
D. Excessive sweating and an increase in blood pressure
and pulse.
24. Zoro is leaving his home for the first time in a year.
He arrived in the unit wearing a surgical mask and white
gloves. He states, “The germs in here are going to kill
me”. Which correctly written nursing diagnosis addresses
Zoro’s problem?
A. Social isolation R/T fear of germs AEB continually
refusing to leave the home.
B. Fear of germs R/T obsessive-compulsive disorder.
C. Ineffective coping AEB dysfunctional isolation R/T
unrealistic fear of germs.
D. Anxiety R/T the inability to leave home, resulting in
dysfunctional fear of germs.
Health problemetiology or cause r/tsigns and symptoms
25. Zoro has been in your care in the psychiatric unit for
4 days now for the treatment of their OCD. Which
outcome takes priority for the patient at this time?
A. The client will use a thought-stopping technique to
eliminate obsessive and/or compulsive behaviors.
B. The client will stop obsessive and/or compulsive
behaviors in order to focus on activities of daily living.
C. The client will seek assistance from the staff to
decrease obsessive and/or compulsive behaviors.
D. The client will use one relaxation technique to
decrease obsessive and/or compulsive behaviors.
Situation
You apply your knowledge on concepts of
PSYCHOSOCIAL HEALTH to patients
assigned to you in the ward.
26. You are attending a seminar regarding coping skills.
You were asked about the beneficial effects of humor.
You respond to the question appropriately based on
which of the following documented beneficial effects of
humor?
A. Lessened depression pet therapy
B. Increased relaxation music tharapy
C. Reduced aggression
D. Improved sleep exercise
27. As a knowledgeable nurse, you know that body
image is the subjective view an individual has about his
or her physical appearance including body shape, size,
weight, and proportions. Which of the following
conditions would put a patient at risk for disturbed body
image?

A. Urinary tract infection
B. Hyperlipidemia
C. Rheumatoid arthritis
D. High blood pressure
28. You are a preoperative nurse preparing a client for an
upcoming surgery. While you’re preparing this patient,
you inform them of what they can expect after surgery
and how their pain will be controlled postoperatively.
Which of the following stress management techniques is
being utilized in this scenario?
A. Relaxation
B. Guided imagery
C. Progressive muscle relaxation
D. Anticipatory guidance
29. An elderly patient you’re caring for is about to be
discharged. Which of the following statements, if made
by the patient, would indicate that they lack a support
system at home?
A. “My sister and her husband are taking me home
today.”
B. “My church members have been sending cards and
letters while I have been in the hospital.”
C. “I am not sure how I am going to get to the grocery
store after I get home.”
D. “My neighbor is retired. We visit and have our meals
together every day.”
30. You are to assess a newly admitted patient regarding
their health care practices. As a culturally competent
nurse, which of the following factors would you include
in your assessment?
I. Health-seeking behaviors
II.Responsibility for health care
III.Folklore practices
IV. Barriers to health care
A. I
B. III
C. I, II, IV
D. I, II, III, IV
Situation
You are caring for various patients with substance abuse
disorder of methamphetamines. You utilize your
knowledge to help care for these patients.
31. You are assessing a patient diagnosed with
substance abuse disorder. They stated, “My wife
causes me to abuse methamphetamines. She uses
methamphetamine and she also expects me to.” As a
knowledgeable nurse, you know that the patient is using
which of the following defense mechanisms?
A. Rationalization.
B. Denial.
C. Minimization.
D. Projection.
32. The mother of one of your patients who are newly
admitted to the mental health unit expresses her concern
that his son may be using methamphetamine. Which
physical examination findings are consistent with
methamphetamine abuse by the client?
Metamphetaminestimulant
A. Hypotension and bradycardia
B. Bruises and scrapes on the extremities gait
alterations because of alcohol
C. Constricted pupils and fatigue
D. Anorexia and recent weight loss
33. One of the patients you’re caring for in the unit is in
methamphetamine withdrawal. When caring for this
patient, the most appropriate intervention by the nurse
should be to?
A. Administer sedatives routinely to prevent seizures.
B. Allow the client to sleep and eat as desired.
C. Administer antipsychotic medications to manage
hallucinations.
D. Encourage involvement in the treatment milieu.
34. You are assessing one of the patients in your unit
who abuses methamphetamine. The patient appears not
to be willing to give up the usage of the drug, as
evidenced by their statement, “I do not plan to quit meth.
I can work for days when I am high.” Which of the
following is your best response to the patient’s
statement?
A. “You’ll exhaust yourself doing that.”
B. “You can’t see the real problem yet because you are in
denial.”
C. “You think using drugs helps you?” restate assist
the client in examining their thought process
D. “Good point. You probably work long hours while
you are on meth.”
35. One of your patients regularly uses projection to
protect themselves against the negative realities resulting
from their methamphetamine use. Which of the
following statements will the nurse most likely document
when the patient uses projection as a coping mechanism?
A. “My dad and I don’t get along because he thinks
that I’m a failure.”
B. “I can’t go back to work. I’d be so embarrassed for
anyone to find out I’ve been in treatment.”
C. “I’m not giving up alcohol, just the
methamphetamine. I never had a problem with alcohol.”
D. “Everything will be all right again if I can just stop
using drugs.”
Situation
You are caring for Robin, a patient diagnosed
with MULTIPLE SCLEROSIS. The following
questions apply.
36. Robin is scheduled for a magnetic resonance imaging
(MRI) scan of the head. Which of the following
information should you relay to Robin about the test?
A. The client will have wires attached to the scalp and
lights will flash off and on. EEG
B. The machine will be loud and the client must not
move the head during the test.
C. The client will drink a contrast medium 30 minutes to
one (1) hour before the test.
D. The test will be repeated at intervals during a five (5)-
to six (6)-hour period.
37. Robin stated her frustration regarding her recent
diagnosis of MS. She states, “I do not understand how I
got this disease. Is it genetic?” On which statement
should you base your response?
A. Genetics may play a role in susceptibility to MS,
but the disease may be caused by a virus.
B. There is no evidence suggesting there is any
chromosomal involvement in developing MS.
C. Multiple sclerosis is caused by a recessive gene, so
both parents had to have the gene for the client to get
MS.
D. Multiple sclerosis is caused by an autosomal
dominant gene on the Y chromosome, so only fathers can
pass it on.
38. Which of the following issues presented by Robin is
of most importance to you at this time as her primary
nurse?
A. She refuses to have a gastrostomy feeding.
B. She wants to discuss if she should tell her fiancé.
C. She tells the nurse life is not worth living anymore.
Safety and security
D. She needs the flu and pneumonia vaccines.
39. Robin stated that she has been investigating
alternative therapies to treat her disease. Which of the
following interventions is most appropriate? Massages ,
relaxation techniques
A. Encourage the therapy if it is not contraindicated
by the medical regimen.
B. Tell the client only the health-care provider should
discuss this with him.
C. Ask how his significant other feels about this
deviation from the medical regimen.
D. Suggest the client research an investigational therapy
instead.
40. You enter Robin’s room after her diagnosis of acute
exacerbation of MS. You find her crying. Which of the
following statements is the most therapeutic response
you can make as her nurse?
A. “Why are you crying? The medication will help the
disease.”
B. “You seem upset. I will sit down and we can talk
for awhile.” Acknowledge or offer self
C. “Multiple sclerosis is a disease that has good times
and bad times.”
D. “I will have the chaplain come and stay with you for a
while.”
Situation
You are caring for patient Luffy who has seizures. You
apply your knowledge on concepts of seizures to better
assess, diagnose, plan, and evaluate their condition.
41. Luffy is sitting in the chair when suddenly, his
entire body went rigid with his arms and legs contracting
and relaxing. He is not aware of what’s going on and is
making guttural sounds. Which of the following actions
should you implement first?
A. Push aside any furniture.
B. Place the client on his side.
C. Assess the client’s vital signs.
D. Ease the client to the floor.
42. Luffy is scheduled for an electroencephalogram
(EEG) to help diagnose a seizure disorder. Which of the
following preprocedure teaching should you implement?
A. Tell the client to take any routine antiseizure
medication prior to the EEG.
B. Tell the client not to eat anything for eight (8) hours
prior to the procedure. Dec. bloodsugar Alter brain wave
pattern
C. Instruct the client to stay awake for 24 hours prior
to the EEG.
D. Explain to the client that there will be some
discomfort during the procedure.
Sleep deprivation Enduce seizure EEG, Patient will have
seizure diagnosis of seizure disorder
43. Luffy just had a 3 minute seizure. He has no
apparent injuries, is oriented to name, place, and time
but he is very lethargic and just wants to sleep. Which of
the following interventions should you implement?
A. Perform a complete neurological assessment.
B. Awaken the client every 30 minutes.
C. Turn the client to the side and allow the client to
sleep.
D. Interview the client to find out what caused the
seizure
44. Which statement by Luffy indicates that he
understands factors that may precipitate his seizure
activity?
A. “It is all right for me to drink coffee for breakfast.”
Avoid stimulants
B. “My menstrual cycle will not affect my seizure
disorder.” Onset menses  enduced sizure
C. “I am going to take a class in stress management.”
Stress induce seizure
D. “I should wear dark glasses when I am out in the sun.”
avoid bright light
45. Luffy is prescribed the anticonvulsant phenytoin
(Dilantin) for his seizure disorder. Which statement
indicates that Luffy understands the discharge teaching
regarding this medication?
Phenytoin(Dilantin) -Gingival hyperplasia
A. “I will brush my teeth after every meal.”
B. “I will check my Dilantin level daily.”
C. “My urine will turn orange while on Dilantin.”
D. “I won’t have any seizures while on this medication.”
Situation
You are a new nurse assigned in the operating room. You
will apply your knowledge on perioperative nursing to
effectively and safely handle patients in this area.
46. You are preparing your patient for an upcoming
surgery. Which of the following interventions should you
implement first?
A. Check the permit for the spouse’s signature.
B. Take and document intake and output.
C. Administer the sedative.
D. Complete the preoperative checklist.
47. You are conducting an interview with the surgical
patient in the holding area. Which of the following
information should you report to the anesthesiologist?
Select all that apply.
I. The client has loose, decayed teeth.
II. The client is experiencing anxiety.
III.The client smokes two (2) packs of cigarettes a
day.
IV. The client has had a chest x-ray which does not
show infiltrates.
V. The client reports using herbs.
A. I, II, III, IV
B. II, III
C. I, III, V
D. III, V
48. The circulating nurse intervenes when she notices
which of the following violations of surgical asepsis?
A. Surgical supplies were cleaned and sterilized prior to
the case.
B. The circulating nurse is wearing a long sleeve sterile
gown.
C. Masks covering the mouth and nose are being worn
by the surgical team.
D. The scrub nurse setting up the sterile field is
wearing artificial nails. Artificial nailsharbor
microorganism
49. The following statements are not an expected
outcome for the postoperative client who had a general
anesthesia, except? (+)
A. The client will be able to sit in the chair for 30
minutes.
B. The client will have a pulse oximetry reading of
97% on room air.
C. The client will have a urine output of 30 mL per hour.
D. The client will be able to distinguish sharp from dull
sensations. spinal anesthesia/block
50. Which of the following problems should you
identify as the PRIORITY for a patient who one day
postoperative?
A. Potential for hemorrhaging. First 24 hours
B. Potential for injury.
C. Potential for fluid volume excess. deficit
D. Potential for infection.
51. Antibiotics have limited use in the actual treatment of
Mastoiditis because________.*
a. Tissue destruction is extensive
b. It is a long-term treatment
c. Antibiotics do not easily penetrate the infected
bony structure of the mastoid
d. Culture has to be done to identify which antibiotic is
most effective for the treatment of Mastoiditis
Situation
You are a staff nurse in a government hospital being
transferred to the Psychiatric Unit. You were required to
equip yourself by attending the enhancement program on
Crisis Intervention. To assess your knowledge and skills
on the subject you were given a pre-test.
52. A crisis that is acute but temporary and due to an
external source is__________.
a. Developmental
b. Transitional
c. Traumatic ex. Rape
d. Dispositional ex.house fire
53. The MAIN objective of crisis intervention is
to_____________
a. Make the person realize his/her mistakes
b. Ensure patient’s safety
c. Return the person to the root of the crisis to
identify the cause
d. Eliminate the stressor
54. Which of the following is NOT an assumption in the
concept of crisis?
a. Crisis is acute and resolved within a short period of
time 4-6 weeks
b. All individuals experience a crisis
c. Crisis is a growth-retarding factor to the emotional
development of a person
d. Specific identifiable events precipitate a crisis
55. Which of the following nursing interventions is the
most appropriate for a client who is in the early state of
crisis?
a. Encourage client to express feeling and emotions
related to crisis
b. Require client to be actively involved in establishing
goals
c. Encourage client to begin the development of insight
d. Ask client to evaluate the situation
Situation
In the PGH Ear Unit, the staff nurse is attending to
several outpatient clients seeking follow-up care.
56. In administering ear drops, the nurse observes
which of the following principles?
a. In a child, pull pinna upward and backward. ADULT
b. Let the ear drops fall on the middle space of the canal.
c. Lie on the unaffected side to facilitate absorption.
d. Position unaffected ear uppermost.
 the various “improvements” in performance, this
57. The nurse assists in an ear irrigation. Which of the industry is still unwavering.
following statements by the nurse is correct?

61. Caffeine greatly affects which part of the heart, as

a. “Tilt the head towards the unaffected ear.”
reflected in an ECG?
b. “Direct the stream of irrigate at the sides of the ear
canal.”
c. “After the procedure, lie on the unaffected side to a. Atrium
allow the irrigate to soften any hardened mass.” b. Ventricles
d. “This procedure is allowed for otitis media to clean the c. Purkinje fibers
canal.” d. Interventricular septum

58. What makes children more predisposed to chronic 62. Which of the following do not have the potential of
otitis media? addiction, if consumed frequently and in large amounts?

a. Shorter Eustachian tube a. Chocolate-flavored Cola

b. Horizontal orientation of the ear canal b. Apple juice
c. Primary diaphragmatic breathing c. Green tea
d. Both A and B d. Common cold preparations

59. The Psychiatrist orders “Restraints PRN” for a client
who has a history of violent behavior. Nurse Poppy
should:
A. Utilize the restraint order if the client begins to act-out
B. Ask the psychiatrist to clarify the type of restraint
order
63. In the previous situation of the young professional
intoxicated with caffeine, he suddenly was unable to take
any caffeine source for 24 hours already. The nurse
expects to note the following findings, except?
caffeine withdrawal
a. Headache
b. Difficulty in stimulating irritability

C. Ensure that the entire staff is aware of the restraint c. Nausea and vomiting
order d. Muscle pain
D. Recognize that PRN orders for restraints are 64. The nurse suspects caffeine intoxication in a young
unacceptable high risk for abuse professional if he notes which finding?
caffeinestimulant
a. Decreased flow of thought and speech
60. Which of the following is a characteristic sign of b. Psychomotor agitation
acute otitis media in children? c. Urinary retention
d. Pale face warm flushed face
a. Jumping in pain
b. Ear tugging
c. Painless inflammation 65. The following are the reasons why many people
d. Difficulty awakening abuse caffeine. Choose the exception.

a. Relieve fatigue
b. Increase mental alertness
c. Both A and B
d. Neither A nor B

Situation
The student nurse is reviewing for his admission exam
for a prestigious hospital in Taguig City. He is answering
questions related to eye disorders.

66. In the clinic, the school health nurse is conducting a

vision screening to incoming Grade 1 and Grade 4
students. One of the students was able to read at 10 ft,
what a normal eye sees at 20 feet. She documents this
finding as:

me before others

a. 10/20
Situation
b. 20/10
Addiction disorders are unnecessarily common in the
c. 2/1
modern lifestyle of Filipinos, especially with the rise of
d. 1/2
establishments selling products with caffeine. Because of
 a. paresis of both lower extremities
67. A student was not able to read the letters in the 20/20 b. paralysis of one side of the body
level. How should the nurse proceed with the visual c. paralysis of both lower extremities
assessment? d. paresis of upper and lower extremities

a. Document this finding as visual impairment.

b. Allow the student to come nearer at a distance of 10 ft.
c. Ask the student to squint, and try reading the level
again.pinhole occlude
d. Remind the student to avoid guessing at letters to have
an accurate finding.

68. A patient is due to undergo tonometry for

confirmation of the diagnosis of glaucoma. The nurse
advises the patient against which of the following,
except:

a. Squinting Inc IOP

b. Breathing through open glottis
c. Coughing
d. Bending at the hips

69. The nurse is caring for a client following enucleation.

The nurse notes the presence of bright red drainage on
the dressing. Which nursing action is appropriate?
bright red drainage arterial bleed high pressure
bleeding  hemorrhage  shock
a. Notify the physician.
b. Document the finding.
c. Continue to monitor the drainage.
d. Mark the drainage on the dressing and monitor for any
increase in bleeding.
70. The nurse is performing an admission assessment on
a client with a diagnosis of detached retina. Which of
the following is associated with this eye disorder?
a. Total loss of vision blindness
b. Pain in the affected eye closed angle Glaucoma
c. A yellow discoloration of the sclera
d. A sense of a curtain falling across the field of vision
Situation
The diverse Neurologic disorders present unique
challenges of nursing care. The Nurse must have a clear
understanding of the pathologic processes for appropriate
nursing management. Nurse Jeremy is attending to
clients in the ward with Multiple Sclerosis.
71. A recently hospitalized client with Multiple Sclerosis
is concerned about generalized weakness and a
fluctuating physical status. What is the priority nursing
intervention for this client?
a. encourage bed rest muscle athrophy
b. space activities throughout the day
c. teach the limitations imposed by the disease
d. have one of the client’s relatives stay at the bedside
73. Which statement by a client with Multiple Sclerosis
indicates to Nurse Jeremy that the client needs further
teaching?
a. “I use a straw to drink liquids.” Dec. risk aspiration
b. “I will take a hot bath to help relax my muscles.”
Dec. sensation inc risk injury
c. “I plan to use an incontinence pad when I go out.”
Weakness of bladder
d. “I may be having a rough time now, but I hope
tomorrow will be better.” MS: remissions and exacerbations
74. Mr. Dela Cruz a 48 year old client carpenter
admitted after a spinal cord injury and the Physician
indicates that a client is a Paraplegic. The family asks
Nurse Jeremy what this means. What explanation should
the nurse give to the family?
a. upper extremities are paralyzed
b. lower extremities are paralyzed
c. one side of the body is paralyzed
d. both lower and upper extremities are paralyzed
75. Jeremy is excited to be assigned to a Neuro –Ward
after his extensive training. He is preparing to conduct a
Neurologic examination. What nursing intervention is
anticipated for a client in the plateau phase of Guillain-
Barre syndrome?
a. providing a straw to stimulate the facial muscles
b. inserting an indwelling catheter to monitor urinary
output Bladder paralysis
c. encouraging aerobic exercises to avoid muscle atrophy
d. administering antibiotic medication to prevent
pneumonia
Predisposing factor of GBS – Epstein Barr Virus (EBV)

AGN
72. Which clinical indicator does Nurse Jeremy identify Note: Parkland Formula – computation of fluid
when assessing a client with hemiplegia? resuscitation for burns
PF= 4ml x bsa x kg For whole 24 hrs
Divide by 2 – For 8 hrs Divide the next 16 hrs – Remaining
Half
Situation
In the Psychiatric ward nurses are discussing the other
factors that caused Alzheimer's disease (AD). And they
all agree that it is a degenerative disease of the brain
caused by gradual death and loss of brain cells resulting
to progressive and irreversible Dementia.
76. The Nurse develops a nursing diagnosis of self care
deficit for an older client with Dementia. Which of the
following is the most appropriate goal for this client?
DEMENTIA-Dec. intellectual functioning
a. The client will be admitted to a long care facility to
have activities of daily living needs met
b. The client will function at the highest level of
independence possible instill self esteem
c. The client will complete all activities of daily living
independently within one (1 ) hour time frame
d. The Nursing staff will attend to all the client’s
activities of daily living needs during the hospitalization
77. The nurse recognizes that Dementia of the
Alzheimer’s type is characterized by:
a. aggressive acting-out behavior
b. periodic remissions and exacerbations
c. hypoxia of selected areas of brain tissue
d. areas of brain destruction called senile plaques dec,
nerve transmission dec. intellectual functioning
Aluminum exposure – increases risk for Dementia
development
78. When attempting to understand the behavior of an
older adult diagnosed with Vascular Dementia, the nurse
recognizes that the client is probably:
Dementia: dec intellectual functioning
a. not capable of using any defense mechanisms
b. using one method of defense for every situation
c. making exaggerated use of old, familiar mechanism
d. attempting to develop new defense mechanism to meet
the current situation.
79. Which of the following nursing intervention is most
helpful in meeting the needs of an older adult
hospitalized with the diagnosis of Dementia of the
Alzheimer’s type?
dec intellectual functioning
a. providing a nutritious diet high in carbohydrates and
protein
b. simplifying the environment as much as possible
while eliminating the need for choices
c. developing a consistent nursing plan with fixed time
schedules to provide for emotional needs
d. providing an opportunity for many alternative choices
in the daily schedule to stimulate interest
80. A 75-year-old man with the diagnosis of Dementia
has been cared for by his wife for 5 years. For the past 2
years he has not spoken and incontinent of urine and
feces. During the last month he has changed from being
placid and easygoing to agitated and aggressive. He is
admitted to a Psychiatric hospital for treatment with
Psychopharmacology. Which is the priority nursing
care while this client is in the psychiatric facility?
a. managing his behavior
b. preventing further deterioration
c. focusing on the needs of the wife
d. establishing on the needs of the wife
Situation
The ICU nurse assigned to a 60-year old acutely
ill client with Parkinson’s disease who was
hospitalized frequently. The initial confinement
was due to electrolyte imbalance. The following
confinement was due to injury sustained from
fall, he became to have incontinent of stools that
further lead to development of skin irritation
and breakdown. Currently he was admitted due
to respiratory infection.
81. The review of literature does not only include
published research studies but also theory. In this case
which theory is least related to the study? STRESS
STIMULI
a. Neuman’s system model
b. Lazarus’ theory of stress and coping
c. Nightingale’s environmental theory NOT
INCLUDED IN FECAL Act of utilizing the environment to assist
patient in his/her recovery
d. Roy’s theory of adaptation
82. Related literature included case situations similar to
the case of the client. The nurse is interested in gaining
further knowledge that can help the client at risk for fecal
incontinence. The nurse should use which of the
following methods to strengthen this report?
a. Historical research method past issues
b. Qualitative research method phenomenon/ experience
c. Experimental research method
d. Quantitative research method frequency, amount –
require measurements CAUSAL or CORELATED
RELATIONSHIP of 2 VARIABLES
83. The patient also reports multiple lumbar muscle
strains, thus is also looking at using alternative therapies
to reduce the pain. The client seeks advice from the nurse
as to what type of alternative therapy would provide the
best pain relief. How should the nurse respond?
a. "I have seen many individuals with your type of pain
be relieved of pain through the use of acupuncture."
b. "These types of therapies are more than just therapies;
they are really a mind over matter type of event or
game."
c. "Some of my other clients swear by magnet therapy to
reduce pain as it is very small and very easy to use."
 d. "You need to choose the alternative therapy that is
right for you based on research that supports the
intervention."

84. While the nurse was able to identify the cases that
were studied, it is important to understand the
phenomenological experience of the client. This
approach includes the following except: (-)

EXPLORATION ; Bigger picture

a. Exploring the idea expressed by the person

b. Getting the whole picture of fecal incontinence and its
associated factors
c. Focusing interview on fecal incontinence
d. Interviewing and using of questionnaire on client’s
responses to his situation 89. Visual Acuity declines with age. Presbyopia is a
progressive decline in:
85. Which of the following can the nurse use in
protecting the safety of the subjects undergoing the
A. Distinguishing between blues and greens and among
research study?
pastel shades
i. Code for Nurses B. Ability to see in darkness
ii. Nightingale’s pledge C. The ability of the eyes to accommodate for close
iii. Patient’s Bill of Rights detailed work
iv. Human Rights Guidelines D. Adaptation to abrupt changes from dark areas to light
areas
a. 1, 2, 3, 4
b. 1, 3
c. 1, 2 90. The novice nurse who is administering a beta blocker
d. 3 only asks the Senior Staff Nurse about its effect on the
Autonomic Nervous System. When formulating a
Situation response the nurse should understand which common
In a Nursing Practice you are directly involved misconception about the Autonomic Nervous System?
in conducting a comprehensive physical
assessment especially to older clients with A. both sympathetic and parasympathetic impulses
continually affect most visceral effectors
sensory limitations. B. the autonomic nervous systems is regulated by
86. The client with head injury is having problems with impulses from the hypothalamus and other parts of the
several sensory functions. Nurse Ymir should understand brain
that the structure that acts as a relay center for sensory C. sympathetic impulses stimulate while
impulses is the: parasympathetic impulses inhibit the functioning of
any visceral effector
A. thalamus D. visceral effectors (e.g., cardiac muscle, smooth
muscle, glandular epithelial tissue) receive impulses only
B. cerebellum
via autonomic neurons
C. hypothalamus
D. medulla oblongata SNS inhibit GIT BladderConstipation urinary retention

87. When formulating nursing care plans for older adults,
Nurse Ymir should include special measures to
accommodate for age-related sensory losses such as:
A. difficulty in swallowing
B. increased sensitivity to heat
C. diminished sensation of pain
D. heightened response to stimuli
88. After a brain attack a client remains unresponsive to
sensory stimulation. Nurse Ymir understands general
sensations such as heat, cold, pain, and touch are
registered in the:
A. frontal lobe
B. parietal lobe
C. occipital lobe
D. temporal lobe
PNS
Situation
Poppy a Psychiatric Nurse responds in a variety setting
to different clients with Personality disorders.
91. The Psychiatrist orders “Restraints PRN” for a client
who has a history of violent behavior. Nurse Poppy
should:
A. Utilize the restraint order if the client begins to act-out
B. Ask the psychiatrist to clarify the type of restraint
order
C. Ensure that the entire staff is aware of the restraint
order
D. Recognize that PRN orders for restraints are
unacceptable high risk for abuse
92. Strict toilet and too early training to a toddler child
will cause problems in personality development because 97. When planning to teach about the stages of growth
at this age a child is learning to: and development, what stage does the nurse indicate as
basically concerned with role identification?
A. Satisfy own needs
B. Identify own needs A. Oral stage
C. Satisfy parents’ needs B. Genital stage
D. Live up to society’s expectations C. Oedipal stage
D. Latency stage
Toddlerhood: autonomy vs shame and doubt

93. The nurse encourages a client to join a self-helping 98. The nurse understands that Freud’s phallic stage of
group after being discharged from a Mental health psychosexual development, which compares with
facility. The purpose of having people work in a group Erikson’s psychosocial phase of initiative versus guilt, is
is to provide: seen best at:
A. Support A. adolescent
B. Confrontation B. 6 to 12 years
C. Psychotherapy C. 3 to 51/2 years
D. Self-awareness D. birth to 1 year

94. As Depression begins to lift, a client is asked to join a
small discussion group that meets every evening on the
unit. The client is reluctant to join because, “I have
nothing to talk about.” What is the best response by the
nurse?
A. “Maybe tomorrow you will feel more like talking.”
B. “Could you start off by talking about your family?”
C. “A person like you has a great deal to offer the
group.”
D. “You feel you will not be accepted unless you have
something to say?” Reflective statement allow client
to validate the nurse
95. A client on the Psychiatric unit asks Nurse Poppy
about Psychiatric Advance Directives (PAD). The
nurse explains that these advances directives:
99. A 3 year old boy was brought to a Pediatric clinic for
indifferent behavior. About a month after their toddler is
diagnosed as moderately retarded, the parents discuss the
toddler’s future, reflecting specifically on plans for their
child’s independent functioning. The nurse recognizes
that the parents:
A. Are using denial
B. Accept the child’s diagnoses
C. Are using intellectualization
D. Accept their child’s limitation
100. The nurse utilizes play when interacting with
children based on the understanding that play for the
preschool-age child is necessary for the emotional
development of:

A. Make the appointment of a surrogate decision maker A. Projection

unnecessary B. Introjection
B. Permit the client to dictate what treatments will be C. Competition school age
given during future hospitalization D. Independence influence by the environments
C. Eliminate the need for involuntary admissions when
the client is a threat to self or others
D. Allow the client, while having the capacity, to
consent or refuse potential psychiatric treatments in
the event of a future incapacitating mental health
crisis

Situation
The fundamental assumption of theory of life cycle
theories is that development occurs in successive stages.
The different life cycle theories try to explain personality
development as well as development of Psychiatric
disorders. The following questions refer to this situation.

96. The nurse understands that problems with

dependence versus independence develop during the
stage of growth and development known as:

A. Infancy
B. School age
C. Toddlerhood
D. Preschool age